Illustration by Sarah Ferone
Illustration by Sarah Ferone

The meaning of mergers

Industry leaders make their predictions about the future of hospitalist jobs.

For hospitalists scanning the horizon, some recent trends might feel a bit unsettling—a heightened focus on outpatient treatment, mergers of health care systems, and hospital closures, particularly in rural areas.

There's still plenty of work available for hospitalists committed to the specialty, particularly as baby boomers move into their later years, according to industry experts. But the nature of hospitalist jobs could shift in years to come, they said.

Potential changes include hospitalists being relied upon to anticipate and address a patient's medical care needs not just in the hospital but during the initial weeks following discharge. Telemedicine and other tech-related tools will be more frequently tapped to assist rural hospitals and others struggling to retain sufficient physicians. And hospital physicians may need to become more accustomed to practicing in teams with other clinicians if they want to regain time for the direct patient care they most enjoy, said Leslie Flores, a partner at Nelson-Flores, a California-based hospitalist management firm.

But don't be too quick to assume that these merged systems will require fewer hospitalists, said Ms. Flores and other industry experts.

Depending upon how a new larger health system is structured, there might be opportunities within the hospitalist corporate structure and also in other administration jobs that might open up, such as in information technology or quality roles, Ms. Flores said.

In fact, hospitalists might be among the best situated of physicians as systems transition to bundled payments and other new reimbursement models, said Terry McGeeney, MD, a health care consultant in Kansas City, Kansas.

“[Hospitals] are starting to look at a bit of an evolving role for hospitalists, to maybe even have one follow-up visit after the patient leaves the hospital,” Dr. McGeeney said, “to make sure all of the care is coordinated and the patient doesn't bounce right back.”

A maturing profession?

The number of hospitals continues to steadily decline despite the growing U.S. population, down from 5,359 nationally in 2013 to 5,262 in 2017, according to the most recent American Hospital Association statistical report.

Mergers also continue apace; some 90 mergers and acquisitions were announced in 2018, according to a recent report from Kaufman Hall. The Chicago-based health care consulting firm also cited a trend toward mega-system mergers, such as the one last year involving Bon Secours Health System and Mercy Health. At the same time, nearly 100 rural hospitals have closed their doors since January 2010, according to data from the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill.

But recruiters are still searching for hospitalists. The specialty ranked #7 in the top 20 list of most requested specialties, according to Merritt Hawkins' most recent report, published in 2018. Even so, there has been a bit of a decline in activity. The annual number of hospitalist recruiting searches ranged from 94 to 118 during the most recent two years compared with 176 to 231 during the three prior years.

Travis Singleton, a Merritt Hawkins executive vice president, chalks that up to a maturation in the hospitalist market compared with when the specialty was first emerging. “On the heels of a five-year merger market, I think pretty much if you need a hospitalist program you probably have one by now,” Mr. Singleton said. “We are not seeing these new programs every year.”

Pay has stabilized for similar reasons, Mr. Singleton said. The average pay for a hospitalist, which was $229,000 in 2013/2014, only increased $5,000 between the two most recent years, reaching $269,000 in 2017/2018, according to the same Merritt Hawkins report. Pay tends to rise more rapidly when new hospitalist programs are being created and facilities have to staff up quickly or fill more senior-level positions, Mr. Singleton said.

But two key trends also have been converging over the last several years, raising “some existential questions” for the hospitalist workforce in the years ahead, Ms. Flores said. On one hand, hospitalists complain of burnout from documentation and other patient coordination logistics that leave scant time for diagnosis and direct patient care, she said.

Meanwhile, hospitalist leaders are watching their budgets swell as more clinicians are needed for direct care and comanagement. Ms. Flores pointed out in a recent blog post that today's hospitalists are responsible for an increasing proportion of hospitals' patients, 75% in 2018 versus 70% in 2016. “And there aren't that many costs in a hospitalist group other than labor costs. There are really little or no economies of scale with hospitalist groups,” Ms. Flores said.

She noted that these two trends are in some ways meeting in the middle. “We have to move toward something that hospitals can afford to pay for, and that doctors want to do for a career,” she said.

Shifting job description

One piece of the solution will involve hospitalists working more frequently in teams along with physician assistants and nurse practitioners, potentially with more documentation support from scribes, according to Ms. Flores. That additional help is vital, given that hospitalists' role will broaden as more integrated health systems are created, which will extend the cost and quality focus beyond the hospital walls, she said.

Hospitalists also will need to know more about skilled nursing facilities, long-term acute hospitals, and other facilities where they might discharge patients, predicted Robert Bessler, MD, founder and chief executive officer of Sound Physicians, a national health care practice based in Tacoma, Wash.

“The traditional hospitalist 10 years ago was totally focused on, ‘How do I get the patient out?’ It was length of stay, length of stay, length of stay,” Dr. Bessler said. “That is still the number one most important financial metric that hospitals care about, and we focus on that. But it's not just get them out at all costs, but get them to the right next place of service.”

As health care evolves, some hospitalists might find themselves working outside the traditional inpatient floor, said Kevin Schulman, MD, FACP, a professor of medicine, researcher, and clinical hospitalist at Stanford University School of Medicine in California.

Patients these days must be acutely ill to be hospitalized, Dr. Schulman said. But a patient who was backed up by a full clinical team on a Monday doesn't typically qualify for much more than a short primary care appointment when discharged on a Tuesday, he said.

Physicians, perhaps in new positions such as “outpatient intensivist,” will have to start addressing that crucial treatment gap, Dr. Schulman said. “Hospitalists have to think of themselves not as taking care of people in the hospital, but taking care of really sick people,” regardless of where they are, he said.

A shift toward bundled payments specifically will drive a new hospitalist role, as payment is increasingly attached to a bundle of care that extends at least 30 days from discharge, and sometimes beyond, Dr. McGeeney said. In current CMS projects on hip and knee replacements, the cost and quality of care are tracked for 30 days and even up to 90 days after hospital discharge.

That's one of the drivers for health systems to acquire not just physician practices but also skilled nursing and rehabilitation facilities among other postdischarge facilities—to better control the total cost and quality of care, Dr. McGeeney said. “If the patient ends up bouncing back into the hospital, there is no extra reimbursement for that,” he said.

Merger ripple effects

Depending on where hospitalists are practicing, and their personal preferences, mergers might not always be welcome news, Ms. Flores said. For hospitalists who prefer the autonomy of their smaller independent group, a merger will likely bring with it a larger corporate bureaucracy and more rules and standardization about anything from one's approach to clinical work and staffing to compensation, she said.

Larger merged health systems also can exert more leverage in negotiations, Ms. Flores said. Her firm recently worked with a health system that sent a request for proposal to all of the big hospitalist staffing companies. The system's leaders, she said, “were trying to leverage the size of the health system and its buying power to get a bigger deal.”

In that scenario, the hospitals under the health system weren't going to be required to use the staffing company and could continue to use their own employed hospitalists, Ms. Flores said. “But I could see a future in which a staffing company might go to a health system and say, ‘Look, if you give us all of your hospitals across the system, we'll give you a better price.’”

In other scenarios, mergers can open up new job roles for hospitalists to assist far-flung rural hospitals that are acquired as part of a merger and have struggled with onsite physician coverage overnight, Ms. Flores said.

“So you might have one hospitalist who's working during the day in your little rural hospital,” she said. “But at night that coverage is now being provided by some hospitalist at the big hospital 200 miles away, but it's being done by telemedicine.” An added bonus, Ms. Flores noted, is that better night coverage will boost the odds of retaining the daytime hospitalist.

Already Ann Baker, MD, an ACP Member and a hospitalist, can consult with physician colleagues and admit patients across seven hospitals in Virginia and two other states, working nights as a telehospitalist. Dr. Baker, who practices full-time for Sound Physicians at a suburban Richmond hospital, has worked a handful of night shifts monthly since last fall as Sound expanded into telemedicine.

In some cases, Dr. Baker has provided backup coverage for inpatient physicians practicing onsite. With a rural hospital in Washington State, where there's typically no inpatient physician overnight, Dr. Baker handles all of the nighttime admissions, working with the onsite emergency physician.

At an urban Virginia hospital that's more psychiatric focused and also doesn't have an inpatient night physician, Dr. Baker similarly works with the emergency physician and uses video technology in the hospital room to interact with the patient. “You remote in and see them like a normal encounter,” she said. “For me, it's been a different level of reward—getting outside the hospital I usually work at.”

To better prepare the next generation of hospitalists, Dr. Schulman and others stress that medical education and training must better incorporate a diverse array of skills—from developing team-based leadership skills to becoming more technologically savvy to understanding the underpinnings of health care reimbursement.

But the job security of hospitalists, along with a few other specialties such as emergency physicians, is practically built into the equation as leaders of larger health systems wrangle with the next phase of reimbursement, Dr. McGeeney said.

“I think hospitals are going to pay a lot of attention to hospitalists,” he said, “as a way to generate revenue, manage revenue, and manage risk. They're in a good spot.”